Chapter 5 Introduction to the Nursing Process PDF

Preview

Summary

Notes from Fundamentals of Nursing Yoost/Crawford...

Description

!

CHAPTER 5: INTRO TO THE NURSING PROCESS ! KEY TERMS! assessment - The organized and ongoing appraisal of a patient's well-being.! Clinical Care Classification (CCC) - System that provides nursing diagnosis taxonomies for electronic medical record (EMR) systems.! evaluation - Examination of goal or outcome attainment by focusing on the patient and the patient's response to nursing interventions.! implementation - Initiation of appropriate interventions designed to meet the unique needs of each patient.! International Classification for Nursing Practice (ICNP) - Provides an international standard that facilitates the description and comparison of nursing practice locally, regionally, nationally, and internationally.! NANDA International, Inc. (NANDA-I) - formerly the North American Nursing Diagnosis Association.! nursing diagnosis - Identification of an actual or potential patient problem or response to a problem based on the clinical judgment of the nurse.! nursing process - The systematic method of critical thinking used by professional nurses to develop individualized plans of care and provide care for patients. The framework nurses use to provide care.! outcome identification - Observable behaviors or actions that indicate attainment of a goal. Added in 1991.! planning - Phase of the nursing process during which the nurse prioritizes a patient's nursing diagnoses, establishes short and long-term goals, chooses outcome indicators, and identifies interventions to address patient goals.! ! “ANd PIE": Assessment, Nursing diagnosis, Planning, Implementation, and Evaluation! ! The characteristics of the nursing process are:! Analytical - requires nurses to think analytically using critical thinking! Dynamic - changes over time in response to patients needs! Organized - following steps of nursing process ! Outcome oriented - care plans, working towards goal! Collaborative - communication amongst others! Universally adaptable - equally useful method for addressing needs of a specific group of people! ! Medical diagnoses are labels for diseases, whereas nursing diagnoses consider a patient’s response to medical diagnoses and life situations as well as make clinical judgments based on a patient’s actual medical diagnoses and conditions.! ! The essential qualities of short term and long term patient goals are patient focused, realistic, and measurable. ! During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific Nursing diagnosis to provide greater clarity and universal understanding by all care providers. During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient’s goals are met, examine s the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised. Standing orders are written by physicians and list specific actions to be taken by a nurse or other health care provider when access to a physician is not possible or when care is common to a certain type of situation, such as what to do if a patient experiences chest pain or what actions to take after a colonoscopy. Protocols are written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physician’s order. Health care agencies have established protocols outlining procedures for admitting patients or handling routine care situations. Clinical pathways, sometimes referred to as care pathways, care maps, or critical pathways, are multidisciplinary resources designed to guide patient care....